Proud to be a Urinary Tract Infection 101 NURSE ANTIBIOTIC STEWARD For Nurses Nurses Take Antibiotic Stewardship Action Initiative This material was supported in part by a U.S. Centers for Disease Control and Prevention (CDC) contract to Johns Hopkins University. The Department of Antimicrobial The Office of Antibiotic Stewardship, Stewardship, The Johns Hopkins Centers for Disease Control and Hospital: Prevention: • Valeria Fabre, MD • Arjun Srinivasan, MD • Sara E. Cosgrove, MD, MS • Lauri Hicks, DO • Ashley Pleiss, RN, BSN • Melinda Neuhausser, PharmD Disclaimer: The conclusions in this presentation are those of the JHU authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. 1 Proud to be a NURSE Urinary Tract Infections ANTIBIOTIC STEWARD Consists of an infection of: • Kidneys (Pyelonephritis, renal abscess) OR • Bladder (Cystitis) To make a diagnosis of UTI, the following 3 elements are needed: Symptoms + White cells in the + Positive urine culture urine (except in (bacterial growth in neutropenic patients) urine culture) 1. CYSTITIS: Dysuria, frequency, urgency 2. PYELONEPHRITIS: Fever and flank pain 3. CATHETER-ASSOCIATED UTI: Fever and suprapubic tenderness 2 Proud to be a What Does It Mean To Have NURSE ANTIBIOTIC STEWARD Bacteria In The Urine Without Urinary Symptoms? • This is called asymptomatic bacteriuria (ASB) and is defined as isolation of significant growth of bacteria* in the urine of a person WITHOUT symptoms of UTI • There are only TWO situations in which searching for ASB is recommended: • Pregnant women • Patients undergoing a traumatic urologic procedure where mucosal bleeding is expected (e.g., transrectal prostate biopsy) *Significant bacterial growth is defined as: • No catheter present: ≥ 100,000 (105) CFU/mL of a urinary pathogen • Catheter present: ≥ 1,000 (103) CFU/mL of a urinary pathogen 3 Proud to be a What Does It Mean To Have NURSE ANTIBIOTIC STEWARD White Cells In The Urine? • White cells in the urine, or pyuria, is defined as: • ≥ 10 white cells/mm3 • ≥ 3 white cells/HPF of unspun urine • Presence of urinary catheter • Positive leukocyte esterase • Recent urologic procedure • NSAIDs (e.g., ibuprofen) • White cells may be present in the • Steroids • Proton pump inhibitors urine due to non-infectious causes • Antibiotics (e.g., vancomycin, • Examples of non-infectious penicillin) • Pelvic irradiation due to cancer cases of pyuria • Urinary tract stones • Renal-vein thrombosis • Pyuria with or without bacteriuria is • Interstitial cystitis/nephritis NOT an indication for a urine culture • Systemic lupus erythematous or antibiotic therapy if the patient is ASYMPTOMATIC (exceptions already discussed) 4 Proud to be a Asymptomatic Bacteriuria And NURSE ANTIBIOTIC STEWARD Pyuria Are Common In Certain Patient Populations • Patients with very high prevalence of ASB and pyuria (≥ 90%): • Dialysis patients • Patients with long-term indwelling catheters • Patients with moderate (30-50%) prevalence of ASB and high (90%) prevalence of pyuria: • Elderly women • Long-term care residents • Patients with lower (< 10%) prevalence of ASB and moderate (30-50%) prevalence of pyuria: • Short-term catheters (in place for < 30 days) • Pre-menopausal women 5 Proud to be a NURSE Treatment Of ASB: Why Not? ANTIBIOTIC STEWARD • Treatment of asymptomatic bacteriuria is not recommended in most patients (exceptions mentioned earlier) because of the potential harm associated with antibiotics and the lack of clinical benefit. • Some studies have shown an increase in UTIs when asymptomatic bacteriuria was treated, suggesting a protective effect of these urinary bacteria. • Adverse events associated with antibiotic use may occur in 1/5 of patients receiving antibiotics. • e.g., renal failure, C. difficile colitis, cardiac arrhythmias, inflammation/rupture of tendons, anemia, liver inflammation 6 Proud to be a NURSE Special Populations ANTIBIOTIC STEWARD • Elderly patients • Bacteriuria and delirium are independently common in elderly patients. • Delirium or fall should not prompt a urine culture if there are no local genitourinary symptoms (e.g., suprapubic pain) or other signs of infection (e.g., fever or hemodynamic instability). • Spinal cord injury patients • Clinical signs and symptoms of a UTI may differ from persons with normal sensation (presenting symptoms may include increased spasticity, leaking around the catheter, malaise). • Both of these patient groups are at a higher risk of inappropriate antibiotic treatment as their urine is frequently cultured for non-specific symptoms. 7 Proud to be a NURSE The Color Does NOT Tell ANTIBIOTIC STEWARD • Many non-infectious causes may alter the appearance of the urine. • Pale yellow/clear: good hydration • Bright yellow: B vitamins • Red: blood, beets, blackberries • Orange: dehydration, carrots, rifampin • Green: phenol drugs, antidepressants, dyes in food, bile • Brown: anti-psychotics, laxatives, muscle relaxants, muscle injury • Purple: porphyria • Isolated urine color changes (“dark”, “murky”, “cloudy”) do not correlate well with UTI and should not prompt urine cultures in the absence of other signs and symptoms of infection. Proud to be a NURSE The Smell Does NOT, Either! ANTIBIOTIC STEWARD • Strong urine smell is thought to be secondary to ammonia production. • Reasons for odorous urine: • Uncontrolled diabetes • Diet (e.g., asparagus) • Vitamins • Concentrated urine (dehydration) • Urine odor (including foul smell) is not an accurate predictor of UTIs. • Smell of urine is often a misleading symptom of UTIs and results in error. 9 Proud to be a Common Reasons For Inappropriate NURSE ANTIBIOTIC STEWARD Culture/Decision To Treat ASB • Pyuria • Admission or transfer to a • Foul smelling urine new unit/hospital • Dark urine • Leukocytosis (increased white blood cell count in • Sediment in urine blood) • Prior UTI diagnosis • Test of cure • Resistant organisms in urine • Vague malaise/weakness • Fall 10 Proud to be a NURSE Treatment ANTIBIOTIC STEWARD • If a patient is able to take oral medications, oral options are preferred for cystitis and recommended for pyelonephritis once the patient has improved (to avoid complications of intravenous access such as phlebitis, bacteremia, and thrombosis). • Duration: o Cystitis: 3-7 days depending on antibiotics o Pyelonephritis: 5-14 days depending on antibiotics o CAUTI: Remove catheter (this alone may resolve the infection). Duration depends on location and severity of illness (3-14 days). o Longer courses for cases with urinary obstruction • If an antibiotic was started for a suspected UTI and subsequently an alternative diagnosis is identified, antibiotics should be stopped. 11 Proud to be a NURSE ANTIBIOTIC Urine Culture Collection DON’Ts STEWARD Indwelling catheter urine: • Do not collect urine from the drainage bag because growth of bacteria outside the catheter may have occurred at this site. • Urine catheter tip cultures are not acceptable. 12 Proud to be a NURSE Urine Collection DO’s ANTIBIOTIC STEWARD Indwelling catheter urine: 1. Clean the catheter with an alcohol pad. 2. Use a sterile needle and syringe to puncture the tubing or use the urine vacutainer. 3. Aspirate the urine directly from the tubing. 4. Transfer the urine to a sterile specimen container or appropriate transport media. Midstream urine (instructions to patients): 1. Wash hands. 2. Clean area with towelette. 3. Void ~20 mL into toilet and catch portion of the remaining urine in cup without stopping the stream. 13 Proud to be a NURSE When To Order A UA Versus A ANTIBIOTIC STEWARD UA With A Urine Culture? • If a UTI is suspected based on signs and symptoms of UTI (not a fall, not fatigue) either a UA with reflex or a UA plus a urine culture can be ordered • If a UA with reflex is ordered, the clinical laboratory will set the urine culture if predefined criteria are met (usually based on pyuria, nitrite [comes from some urinary bacteria], or leukocyte esterase [comes from white cells]) 14 Proud to be a NURSE ANTIBIOTIC Should I Collect Urine for Bacterial Culture? STEWARD Algorithm for Inpatients with or without a Urethral Catheter* Developed by The Johns Hopkins Hospital Department of Antimicrobial Stewardship START HERE NO/CAN’T GIVE HISTORY YES YES NO Do not collect a urine specimen for bacterial culture for: Isolated dark, cloudy urine Yes Isolated foul-smelling urine YES NO Pyuria in asymptomatic patients Bacteriuria in asymptomatic Bacteriuria in asymptomatic patients After treatment to document cure “Weakness” Falls YES NO History of UTI Routine on admission *This algorithm does NOT apply to patients After urethral catheter change with neurogenic bladder, pregnant women Mental status changes without or patients undergoing urologic procedures evidence of systemic infection or where mucosal bleeding is expected UTI symptoms Nicolle et al., Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America 15 References Slide 3 • IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria, Clin Infect Dis 2019. • Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from IDSA, Clin Infect Dis 2010. Slide 4 • Wise and Schlegel. Sterile Pyuria, NEJM 2015;372:1048-54. • Glen, Peter et al. “Sterile pyuria: a practical management guide.” The British journal of general practice : the journal of the Royal College of General